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October 8, 2013

Adherence To The ‘Guidelines For Management Of Severe Traumatic Brain Injury’ Saves Lives

by editor

Researchers found a significant reduction in the number of deaths of patients hospitalized in New York State with severe traumatic brain injury (TBI) between 2001 and 2009. The Brain Trauma Foundation, in collaboration with the American Association of Neurological Surgeons, published the first edition of the "Guidelines for Management of Severe Traumatic Brain Injury" in 1986. Data from 22 trauma centers in New York State were studied by researchers from Weill Cornell Medical College, the Brain Trauma Foundation, and Jamaica Hospital Medical Center in New York, and Oregon Health & Science University in Portland, Oregon. The reduction in deaths at the trauma centers between 2001 and 2009 corresponded to increased adherence to tenets of the Guidelines, particularly recommendations on monitoring of brain pressure and management of brain perfusion pressure. Detailed findings of this study are reported and discussed in "Marked reduction in mortality in patients with severe traumatic brain injury. Clinical article," by Linda M. Gerber, Ph.D., Ya-Lin Chiu, M.S., Nancy Carney, Ph.D., Roger Härtl, M.D., and Jamshid Ghajar, M.D., Ph.D., published today online, ahead of print, in the Journal of Neurosurgery.

As part of a quality improvement initiative supported by the New York State Department of Health, the Brain Trauma Foundation set up an online Internet database, TBI-trac®, in 2001. The database contains data from pre-hospital sources, emergency departments, and intensive care units at 20 Level I and 2 Level II trauma centers in New York State. Using this database, the trauma centers can upload data on patients with severe TBI, track adherence to the Guidelines, and test hypotheses that may lead to improvements in the Guidelines.

To track how effective the Guidelines have been in reducing the number of deaths due to severe TBI, Gerber and colleagues examined data from the TBI-trac® database for the years 2001 through 2009, focusing on trends in adherence to the Guidelines over time. These trends were evaluated by examining data on intracranial pressure monitoring, use of steroid medications, nutritional intake, treatment thresholds for cerebral perfusion pressure and intracranial hypertension, presence of systemic hypotension, and treatment of intracranial hypertension within the first 1 or 2 days of hospitalization. The researchers also examined changes in the rate of case fatalities within the first 2 weeks after a severe TBI occurred. Studies have shown that approximately 85% of deaths from TBI occur during that time period. Data on 2347 cases of severe TBI were available for the analyses; the mortality analysis was based on 2320 cases due to a lack of sufficient documentation in the other 27 cases.

In their data analysis, the researchers noted a significant reduction in the case- fatality rate from 22% to 13% (p < 0.0001) over the 9-year period. There were obvious signs that adherence to the Guidelines significantly increased over time, with use of intracranial pressure monitoring rising from 56% to 75% (p < 0.0001), adherence to recommended cerebral perfusion pressure treatment thresholds improving from 15% to 48% (p < 0.0001), support for recommendations on nutrition increasing from 41% to 50% (p = 0.005), and the proportion of patients with elevated intracranial pressure (greater than 25 mm Hg) decreasing from 42% to 29% (p = 0.0001). Adherence to the Guidelines' recommendations concerning avoidance of steroid medications was high throughout the time period, and hospital rates of systemic hypotension in patients with severe TBI remained low.

The researchers found that the rates of intracranial hypertension and death in patients with severe TBI decreased significantly over the 9-year period, and these decreases were concurrent with increased monitoring of intracranial pressure and management of cerebral perfusion pressure—two major recommendations of the Guidelines. Gerber and colleagues conclude that adherence to the Guidelines' recommendations on increased monitoring of intracranial pressure and management of cerebral perfusion pressure improved outcomes in patients with severe TBI.

Summarizing the importance of the study, Dr. Jamshid Ghajar, president of the Brain Trauma Foundation said, "Traumatic brain injury is the leading cause of death and disability in young people. Developing evidence-based guidelines and putting them into practice to improve outcomes are key priorities for the Brain Trauma Foundation. This remarkable reduction in deaths in New York State exemplifies our continued commitment to evidence-based guidelines."